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Lower urinary tract symptoms in men, age-related (including symptoms of benign prostatic hyperplasia/hypertrophy) - Management
What investigations should I do for a man presenting with lower urinary tract symptoms (LUTS)?

  • Investigations should be guided by the symptoms, history, and examination.
  • Dipstick test the urine to check for blood, glucose, protein, leucocytes, and nitrites.
  • Measure serum creatinine and eGFR (estimated glomerular filtration rate) if clinically indicated, for example when there is any of the following:
    • Chronic high pressure urinary retention — suggested by bedwetting, or enlarged bladder detected on abdominal palpation or percussion.
    • Recurrent urinary tract infection.
    • History of renal stones.
  • Test for prostate specific antigen (PSA) only after discussing the indications for the test and the interpretation of the results, and providing sufficient time for the man to decide if he wishes to have the test.
    • PSA testing is indicated only:
      • If symptoms suggest bladder outlet obstruction due to benign prostatic enlargement — the test result can guide drug treatment.
      • If the man is concerned about prostate cancer or if the prostate feels abnormal on digital rectal examination — the test result can guide assessment of the risk of prostate cancer.
    • Delay testing if any of the following causes of a transiently increased serum PSA level are present:
      • Vigorous exercise — delay testing for 2 days.
      • Digital rectal examination — delay testing for 1 week.
      • Prostate biopsy — delay testing for 6 weeks.
  • Interpreting PSA results can be difficult.
    • An increased serum PSA level can be present with:
      • Prostate enlargement.
      • Prostate cancer.
      • Infection (prostatitis, urinary tract infection).
      • Physical causes, including following vigorous exercise, digital rectal examination, and prostate biopsy.
      • A normal prostate.
    • A normal serum PSA level can be present with:
      • Prostate enlargement.
      • Prostate cancer.
      • Infection.
    • If checking PSA levels in a man using a 5-alpha reductase inhibitor, be aware that:
      • A decrease in PSA levels is seen rapidly, within the first few months of treatment.
      • After 6 months of treatment with a 5-alpha reductase inhibitor, the PSA value should be doubled to make it comparable to levels in men not treated with a 5-alpha reductase inhibitor.

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